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Mr. Gordon, a 52 year-old client who was admitted to the hospital following an MVC (motor vehicle crash). He suffered rib fractures and has

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Mr. Gordon, a 52 year-old client who was admitted to the hospital following an MVC (motor vehicle crash). He suffered rib fractures and has

 Mr. Gordon, a 52 year-old client who was admitted to the hospital following an MVC (motor vehicle crash). He suffered rib fractures and has a laceration along his right thigh. Mr. Gordon states that his pain is 9 on a 0 – 10 scale (0 being no pain, 10 being the worst). In addition his vital signs are: BP 150/88, HR 105, RR 22, SpO2 95% on RA (room air), T 98.6 degrees Fahrenheit taken orally. 

Long term and Short term goals?

Care Plan Assignment

Directions:

Develop a care plan for ACUTE PAIN that includes the following:

· Problem identification

· Short term goal

· Long term goal

· 5 interventions/action with a rational for each intervention. State if the intervention is independent, interdependent or dependent. Make sure to have at least one of each for this assignment

· Also discuss how you would evaluate the short term goal, long term goal, and interventions

 

 

Patient

Mr. Gordon, a 52 year-old client who was admitted to the hospital following an MVC (motor vehicle crash). He suffered rib fractures and has a laceration along his right thigh. Mr. Gordon states that his pain is 9 on a 0 – 10 scale (0 being no pain, 10 being the worst). In addition his vital signs are: BP 150/88, HR 105, RR 22, SpO2 95% on RA (room air), T 98.6 degrees Fahrenheit taken orally.

Care Plan Grading Rubric

Topic

Points Possible

Points Awarded

Problem

1

 

Short term goal

1

 

Short term evaluation (met or not and rational)

1

 

Long term goal

1

 

Long term evaluation (met or not and rational)

1

 

Nursing interventions (5 total, appropriate for meeting goal)

5

 

Nursing Rationales (5 total, appropriately related to intervention)

5

 

Evaluation of Intervention effectiveness

5

 

Total:

20

 

Problem Identification:

Short Term goal: (need a measureable timeframe):

Evaluation of Short Term goal: (met, not met, or partially met AND evaluation)

Long-term goal: (needs a measureable time frame and will take longer to complete than the short term goal)

Evaluation of Long Term Goal: (met, not met, or partially met AND evaluation)

Nursing Outcome Criteria:

List five nursing interventions and rationale for each.

State if intervention is dependent (D), independent (I), or interdependent (ID).

(Cite source for rationales):

Evaluation of effectiveness of intervention as related to goals (appropriate or inappropriate, if inappropriate make appropriate by either determining a new intervention or by rewriting to make appropriate)

1. Intervention:

Rationale:

2. Intervention:

Rationale:

3. Intervention:

Rationale:

4. Intervention:

Rationale:

5. Intervention:

Rationale:

1.

2.

3.

4.

5.

Resources:

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